Nontraditional settings. Another facet of the medical neighborhood is the provision of health care services in nontraditional settings. For example, some grocery stores in our area employ nutritionists to whom we refer patients for nutritional counseling regarding their health in general or a disease process in particular.
Changes in reimbursement also will affect how care is delivered within the medical neighborhood. As we move away from fee-for-service (volume-based) to value-based payments, physicians who have made the transition from working individually with a panel of patients to providing team-based care within a PCMH will be better positioned to meet the goals of health care reform. (See “Team-based care is key inside the PCMH, too”22 below.) Nonetheless, the transition is a dynamic process. With changes in reimbursement and delivery models, physicians also will be expected to develop and implement continuous quality improvement measures so patient care can be continually evaluated and improved.
Now comes the hard part
While a PCMH requires primary care physicians to collaborate with other health professionals, it has the potential to lead to conflicts and debates about who is at the head of the health care team. This is particularly true within mental health services because, while primary care visits are frequently related to psychosocial issues, the mental health and general practice sectors have traditionally been distinct. In recent years, however, coordinated delivery models that integrate primary care and mental health services have been shown to increase access and reduce the stigma associated with mental health services—and to be cost-effective.23
In many ways, moving the primary care culture from the traditional focus on the physician as “captain of the ship” to a physician-led, team-based approach is one of the most difficult tasks for organizations attempting to transform their care delivery models.3,24 Physicians historically have been autonomous providers of medical care, relying on their own experience, expertise, and beliefs to guide decisions about patient care. Now they’re being asked to give up some of the direct control they may have had over patient care decisions and learn to work more collaboratively with other providers, as well as nonclinicians (eg, health coaches), to achieve desired outcomes.3 A successful transition depends on a reimbursement framework in which patient care goals are properly aligned with incentives for primary care physicians to work in a team-based environment.3,25-27
Team-based care is key inside the PCMH, too
In addition to operating as a team with providers in other settings in the medical neighborhood, innovative primary care practices—typically those that have already achieved patient-centered medical home (PCMH ) status—have strong teams within their walls. In “In search of joy in practice: A report of 23 high-functioning primary care practices,” Sinsky et al22 highlight a number of ways in which the practices they studied are maximizing this approach.
Nonphysician care. A number of practices expanded the roles of medical assistants (MAs), nurses, and even nonclinician health coaches. In one case, MAs nearly tripled the time they spend with each patient, to enable them to do medication review, fill out forms, give immunizations, and book appointments for screening tests such as mammography. In another, registered nurses were given standing orders to treat routine problems such as ear infections and urinary tract infections; at a third, health coaches counsel patients with chronic conditions and MAs conduct depression screening, as needed.
Documentation and computerized order entry—which ties up many hours of physician time—is another area in which some practices have adopted a team approach. A number of practices use nurses or MAs as scribes, entering orders and preparing after-visit summaries, for example. Not only are the physicians more satisfied, but the MAs and nurses are happy to have more involvement in patient care, the researchers report.
Communication is crucial to a successful team approach. In some practices, this is accomplished with weekly physician-clinical staff meetings; in others, with brief group “huddles” or by an office design featuring “co-location.” In one example of the latter, MAs and physicians sit side-by-side, so they can easily talk to each other—the doctor could communicate key patient information that the MA would then follow up on, for example. Regular analysis of workflow to identify and address undue delays is an effective team function, as well.
Helping patients help themselves. Moving toward more patient-focused care will also require a concerted effort to increase patients’ engagement in their own health and medical care. In practice, very little of an individual’s time is spent in a physician’s office. Thus, optimal outcomes can be achieved only when patients are actively involved. Helping patients become proactive—ie, by arming them with the knowledge, skill, and confidence to do their part in staying healthy28—also represents a major shift in primary care culture, as patients become active participants in medical decision making rather than passive recipients of physicians’ advice.